For being here and his hard work. After opening statement, well go to secretary shulkin for statement and then members of the committee for q a. Let me say, this meeting is not about whats happened in the past, its about whats happening right now to correct some things that happened in the past. This is an accountability hearing. Ive told the secretary that we want to take the legislation we passed last year on accountability, on appeals, to give them the tools to address the significant problems confronting the veterans of america, vsos of america, and this committee, to begin moving away from the problems of the past and toward the solutions of the future, in particular on appeals, in particular on accountability, in particular on the gi bill, all those things that are important to the veterans and their families. And i pick particularly on the leadership of the va as well. I want to thank secretary shulkin. Ive always been complimentary of him. People say im too nice to him. Im not too nice to him because hes been good to the veterans and ill be good to him as long as he has been. Hes been a forthright leader that were lucky to have, the veterans are lucky to have, and i feel this committee is lucky to have, but we are at the time where there are no excuses. There are no excuses for why we dont correct the problems weve had with hiring, the problems weve had with i. T. , theres no excuse for not correcting problems we have with veterans appeals and all those areas, so this is all about accountability, its all about standing forward, its all about looking at the past and what we did and looking for the results that are to come in the future so that we do a good job for the veterans of the United States of america. Is he still coming . Okay. Mr. Secretary, im going to swear you in for the purposes of this hearing, if youd stand and raise your right hand. Do you solemnly swear or affirm that the testimony you are about to give before the Senate Committee on Veterans Affairs will be the truth, the whole truth and nothing but the truth so help you god . I do. You may be seated. Mr. Secretary, im going to recognize you for your five minutes and well get to the Ranking Member when the Ranking Member shows. Welcome. Thank you. Thank you. Chairman isakson, senator moran, senator boozman, thank you for inviting me here to talk about vas progress. On behalf of the veterans we serve and the employees that serve them, thank you for your staffs tireless, bipartisan work. Its been great. We certainly appreciate and respect your leadership, mr. Chairman, and partnership in establishing those issues that were trying to tackle at the va head on, some of them, as you have said, have lingered for years. I have always said, i think we have the best committees in congress, and thats in large part due to leadership. We agree with that. Yeah, well, i wouldnt say it if it wasnt true, but i took an oath, so. Joining me today, seated behind me, i just want to introduce you, in case i need a lifeline today, peter shelby, our assistant secretary for the Human Resources administration, cheryl mason, our chairman of the board of veteran appeals, dr. Amy farakof, acting secretary for Community Care, and peter, the executive director of the office of accountability and whistleblower protection, and finally, mr. Robert whirley, our director of education services. A year ago at my confirmation hearing before this committee, i testified that id seek major reform and transformation of va. Today, the guide va reform and transformation were focused on five priorities. The first is to provide greater choice for veterans. Second, to modernize our systems. Third to focus our resources on whats most important to veterans. Fourth, to improve the timeliness of how we deliver our services. And fifth, to prevent veteran suicide, which is our top clinical priority. The president s executive order last week, which supported transitioning military members with Mental Health services during that first critical year as veterans is an important step. Thanks in large part to your leadership, which helped us pass legislation in 2017, the legislation i hope well be discussing today, were making progress on all five of those priorities. Appeals reform would be a good example. Its about modernizing antiquated systems and focusing resources while giving veterans more Timely Services and greater choice. Accountability and whistleblower protection is essential to our unwavering commitment to honoring veterans. It too is about sensible, responsive, modern systems that process and support people to make it better. The gi bill gives veterans better choice. Its about greater opportunity, especially for veterans returning to communities to pursue careers and fulfill dreams. Beyond these reforms, we have announced Sameday Services for primary care and Mental Health at every va facility across the country. We have extended Mental Health to veterans with other than honorable administrative discharges. So far, weve disposed of 111 out of 130 vacant or underutilized buildings, we published data publicly on wait time, quality data, Customer Satisfaction data, and last week we published our opioid prescription rates across the country. There are no other Health Systems in the country that publish this type of data. And because of that, i hope its because of that, were earning our Veterans Trust back. At the end of this last year, 70 of veterans who responded to our survey said that they felt like valued customers at va. Thats up from 46 in 2014. Mr. Chairman, members of the committee, were deeply grateful for your role in supporting all those changes and others like them. Theyre immensely important. But when i look back over this year, were still largely managing through incrementalism, patching and repairing old systems and processes and reacting to crises. Vanke still is far short of the kind of bold transformational change that we need to serve veterans in the decades ahead. From health care to benefits, we have to fundamentally and holistically change our Services Delivery paradigm. My objective when it comes to health care for our veterans is to have a fully integrated, interoperable, operationally efficient system thats easy for veterans and employees and Community Partners to navigate. A full spectrum of care for veterans that capitalizes on our foundational services, delivering on our promise to provide worldclass services. We need a consistent, seamless experience for veterans at every va facility across the country. We need a National Network of modern facilities that meets the changing needs of veterans locally, and we need simple, convenient choice for eligible veterans among a network of highquality Community Providers in a single, consolidated program. Mr. Chairman, i applaud your efforts to get this done. Your draft legislation that passed out of this committee is highly responsive to the needs of veterans, and were all grateful for the work that you and the committee have done so far to make this a reality. Benefits are a gateway to va services, and we need benefit determinations to be simpler. Veterans should know what to expect and have more predictability. They shouldnt have to endure the burden of filing claim after claim after claim after claim. Benefits should better enable lifetime of independence and success for veterans, economic opportunity, physical and Mental Wellbeing and Financial Security for the severely disabled. In short, we need to begin an earnest dialogue with stakeholders about veterans benefits. Mr. Chairman, in the days and months ahead, i invite and welcome your support and leadership in helping us define and then pursue the kind of worthy transformational change the va needs so we can all achieve what we hope to achieve. I look forward to your questions tonight. Thank you, secretary shulkin. I appreciate those remarks very much, and i hope the Ranking Members coming. Is he still coming . Beg your pardon . Yes. Yes, okay. Ill start you can start the clock on me. And let me make somewhat of what may sound like an announcement at the beginning of the hearing. The secretary and i have been in a lot of conversations over the past month or so, and i want to thank the secretary for his stated support for what the committee passed out of committee. As we all know, we had a 141 vote, and as we all know, we had some differences of opinion on the veterans choice bill and the care bill that we passed out of committee. And i did everything i could to try and bring about a unanimous Common Ground, but it didnt get totally done. So i made a phone call to the white house and talked with the president. I believe, if im not mistaken, the secretary was on that phone call as well as a number of other people of interest. And the president and this is my repeating what i remember him saying to me, is youre all good guys, youve got Good Solutions on all sides. Yall see if you can work it out. And we tried to get together a couple meetings to work it out, but that didnt materialize one way or the other. My goal as chairman of the committee is to find a positive resolution to no matter what problem i confront, and not because it comes from my wisdom, but my persistence to see to it we keep our eye on the goal, and the goal is choice for our veterans, better Quality Health care, more accountable va. It is my understanding the president and the administrations going to send our committee in the next couple of days some suggestions that theyre looking for that might help us bring about a resolution, and i intend to work with senator moran and other members of the committee to see if we can do that and take to the floor to unanimously support a bill, or a bill that at least everybody had their chance to support and can have their chance to amend on the floor. One way or another, its time our veterans had a veterans policies that served their choices, gave them the choices they need, funded them so they werent subject to the last minute were out of money routines, which this bill does, by the way. We consolidate the stove pipe from seven to one, correct, secretary . And get those things done that we have to do. So i want to announce up front that thats forthcoming. When it gets here, ill get it to the committee. Well begin work on it and try and get ourselves in the regular order to find a bill that we can unanimously get to the floor, one way or another. And if we cant, i then will have made every effort to do so and ill do whatever i can to have it fully vetted on the floor, if necessary. But whatever the case, our veterans deserve the best of us, the best of us is to find a bill that we can agree on, and the best of us is to find the Common Ground to set up that meeting. So, i intend to do that and i appreciate the input the administration has given us and i look forward to continuing to work with them. And i want to extend ive got a little time left. You know, there are three or four things i want to talk about, mr. Secretary. One thing that concerns me deeply is the four positions that remain unfilled at the department. One is your former position. We plucked you out of va leadership to become the leader of va. That was a good idea. The bad idea is it still doesnt have anybody in your place where you were in terms of secretary of health. The assistant secretary of accountability and whistleblower protection is not in place. That person needs to be in place. The undersecretary for benefits, which is a critical position the va needs to be in place, and the secretary for information technology, which is absolutely critical, particularly with the sernor information coming in, has got to be filled somewhere sooner rather than later. I have asked these questions privately and have looked and i know youre trying, but this is one of those things where a for efforts not good enough. We have to figure out a way to get the best folks in the United States of america in these disciplines working for the Veterans Administration and working for our veterans. Can you tell us what progress you have made and what youre doing on those four in particular . Yeah. Let me give you a quick update on that. For our cio candidate, we have made a selection, and that person is now going through a vetting process at the white house. Our indications are that thats moving along smoothly. For the undersecretary of benefits, we had a commission, as you know by law we need to form commission. They selected three candidates. We made our top choice. That person withdrew, and weve now gone on to our second choice. Fortunately, all three candidates are excellent candidates, and that persons also going through vetting at the white house, and they understand the critical nature of this. On the undersecretary of health, we have this is now going to be our Third Commission. Weve had two commissions prior that did not select a candidate. The Third Commission will be chaired by deputy secretary bowman on january 25th and 26th. We have 11 candidates who have applied for that. We hope to have a successful selection out of that Third Commission process by january 26th, of which we would then forward three names on to the president for consideration that would go through vetting. On the assistant secretary for accountability and whistleblower protection, mr. Orourke is the executive in charge of the accountability and whistleblower protection office, and hes here today. That prompts me to tell you what happened this morning in the health committee. We had testimony on disasters and preparedness, and out of the blue, one of the chief people in charge of that for our country took a point to compliment the Veterans Administration and what the veterans hospitals and medical personnel did to help in the rescue of Senior Citizens in houston after the terrible flood, which reminded me of the importance of the va system that is a system that serves a more senior population, and i wanted to compliment you and the doctors on what they did to earn that praise, because thats a real good thing to have. Thank you. From a standpoint of accountability, i want to see some accountability with regard to the appeals process. I read your report and i read your remarks. I know youre working on demonstration project on appeals, is that correct . Yes. What timetable do you have, are you working towards, to move away from a demonstration project to a project thats fact of the matter exactly how were going to handle these appeals in the future to stop the back log from growing and begin to dissipate the back log . Yeah, today the back log stands at 470,000 appeals, so we have a lot of work to do. Because of your legislation, were now implementing a new process, of course. That will be fully implemented in early 2019, but weve actually started to make major improvements already. This year we are on track to do 81,000 appeals. That would be 30,000 more than last year. Just at this period right now of this fiscal year, were at 21,000 appeals. Thats 10,000 more than this time last year, so were Getting Better and faster and weve brought on new staff. Secondly, weve begun, and this was actually because of the feedback that we got the last time that we were together, weve begun to offer veterans now the choice in their legacy appeals to opt into the new process, so they dont have to wait. Weve had 3 of veterans opt in. These are people with long appeals, opt in. This is the pilot project, to the new process. And heres the good news, theyre getting their decisions within 30 days, and 75 of those decisions are going in favor of the veteran. So, its actually a pretty good deal. Instead of waiting five or six years, if they opt in, 30day decision, 75 approval rate, and thats beginning to address those legacy appeals. So appeals. Im hoping through our veteran Services Organizations and your office well encourage more veterans to consider, because its an elective option, to opt into the new process. Theyll get faster decisions and we hope accurate, good decisions for them. My time is up. As it ends i want to say this. I know our vsos are represented here today. We didnt ask them to testify. Theyre going to have their chance to address the entire house and Senate Committees in a few weeks in the annual report. We look forward to their input. I hope the vsos and the agency will do everything they can to did he s disseminate the fact that veterans are given the option to opt out. That is a light years improvement on appeals. I commend you on what you started. Senator moran . Thank you very much. Let me first say im going to depart our hearing as soon as my questions have been answered. But i would pay honor to senator dole, who we will all be in the capitol to honor today, in kansas and perhaps the country theres no more estee maryland public servant. While his Public Service was tremendous, his military service and his commitment to those with disabilities and that the veteran community is exemplary, no one meets that standard. I pay tribute to senator dole. Let me raise a few points and im going to make comment and ask a question, mr. Secretary. First i want to note that your cancellation of contract the contract for region four for Community Care troubles me. I understand that senator heller will raise this topic with you today. You have a request for my Sub Committee on appropriations to explain what happened in that regard. I look forward to that answer. Secondly, ill be submitting several questions for the record. Im interested in knowing the vas efforts in response to the toxic act that became law in december 2016 and finally youve had conversations with me about Electronic Health records originally about a reprogramming and now i see that there are other reasons youre not proceeding and im concerned about whats taking place here. Ive sent you a letter and would ask you to respond to it. Then let me talk about the topic that the chairman mentioned in regard to the bill that passed the committee. I want to direct this not to the chairman but to you, secretary shulkin. Ive been working closely with the chairman, Ranking Member, other members of this committee and those in the va that you designated for me to work with, and with the white house toshs make sure that the future of Community Care for veterans works and works well for veterans and the providers who serve those veterans. Its of utmost important to me to reform choice and pass the right policies that will work for veterans in accessing health care that they deserve. Its also critical that members of congress continue to push for a change in the va culture and promote implementation of policies directed instead of the va, often narrowing the scope and intent of congress. This, in fact, is a conversation that you and i had almost exclusively during our confirmation hearing in february 2017. Pushing for a culture that transforms the va, in my view, we have to hold you and other va leaders accountable. And in my view, too often commitments and pledges made to this committee and individual members on behalf of our veterans follow up experience is typical of what i found with implementati implementation. Va changes course and it forced the intent of congress. You and i had this conversation during your confirmation hearing. On numerous occasions, you and i have met in my office. We have had numerous telephone conversations and in those meetings and in those telephone conversations, you express support for excess standard notice eligibility of choice reform. In every instance, in my view, you led me to believe that you and i were on the same page. What i have what i remember you saying is this. The need for specificity in legislation is there. And then i quote you. If its left to the reg process, nothing in the va will change. You told me that. I learned, though, that you have said something quite different to the chairman of the Ranking Member and im of the opinion that our inability to reach an agreement is in significant part related to your ability to speak out of both sides of your mouth. Double talk. My understanding is that others have had this experience and there is a shared frustration about the circumstance. So, mr. Chairman, you have been sworn to give testimony today. Im looking for a straightforward answer. Yes or no would be good. Do you believe that the Eligibility Criteria to determine whether a veteran can receive care in their community ought to be explicitly linked to the access standards, yes or no . Of course i believe that Eligibility Criteria should be explicitly linked to access standards. And i believe that those access standards need to be developed by the va. And, mr. Chairman, let me ask the secretary, you support the access standards in our bill. Youve told me that. True . I support the access standards in the bill that the Senate Committee passed 141. And those access standards are very similar. The issue is whether they are then tied to eligibility. Why would you not tie the access standards to eligibility . Why have access standards if they dont matter in who is eligible for Community Care . Well, senator moran, first of all, i applaud your efforts to get this right. I think it is grossly unfair to make the characterizations youve made of me and im disappointed that you would do that. But i think that you have i do not disagree with where you want to get to. I do believe that it is our job to give veterans more choice about how and where they get their health care. I think the issue is that i am trying to do this in a way that will work for veterans and work for va. Ive seen, as youve said before, Congress Pass legislation that makes it more complicated and that makes it not work for veterans. What i am trying to do is give you my best advice about how this works. The best way i know how to do it is the way that the committee, 141, passed their vote. I do believe that because of your efforts, we can make those Eligibility Criteria, those access standards clearer to veterans so they understand it. That should be our goal. And to make sure that they do have choice based upon their clinical needs of their condition. Thats what you do in a health care system. Thats what im driving to get at. I dont believe that we are at a far away position here. Were now talking about the best way to implement what we all want for veterans, which is the best care and giving them the most choice they can get in their tha care. Im sorry you take youre disappointed in my approach to this hearing today. I chose my words intentionally. I believe it to be the case. I think you tell me one thing and you tell others something else. And thats incompatible with our ability to reach an agreement and to work together. And i intend to be a member of congress who holds you accountable for what you tell me. I hope the next step is, as the chairman indicated that the white house was sending language. I certainly would welcome a conversation, a discussion among the members of this committee, Ranking Member and chairman, white house and you. This is, as you say, not that difficult. But it is an important issue. Its not one of a matter of a few words. It matters in the result we get for accountability at the va. Chairman, thank you for the opportunity to question the witness. Thank you for your attendance. Two things. I want to echo your praise for senator dole. A Great American, Great American hero, a guy Whose Campaign i ran in the southeastern United States in 1988, i might add. Always been proud of it. Kind of got the political edge because of it. Hes a great humanitarian, great human being and i appreciate the secretary and senator morans candor and their feelings about what im trying to do. Im trying to get us to the point where our dirty laundry is clean, folded, in the cabinets and what were doing works for the veteran. When everybody get ace chance to have their say, all the facts are on the table and were all willing to work together. Thats what this is all about. Thats what i hope comes to the white house. I found out about today, you found out about it today. In a couple of days youll get notice from me when we have the hearing. Thank you, senator, for your input. Please tell the dole family well all get there if i shut my mouth up. Thank you. Thank you. Senator tester, you can ask questions or go, stay, as big as you are, do whatever you want. Ill just ask some questions. Opening statement will be for later. I apologize. I have another committee to get to very quickly. When it came to first of all, welcome mr. Secretary. When it came to the caring for our veterans bill, we consulted with the vsos and, in fact, got support of 26 vsos. We consulted with you and the va to make sure this would work. Members on this committee and off this committee. You said the va believes the future of Community Care should include eight tenants. Those tenants are improve veterans choice of Community Providers in meeting their health care needs. With the folks on veterans clinical needs, to pave the way of all Community Care programs, add convenient care benefits, set timely payment standards, streamline how we pay for care, including care in state veterans homes, medical records sharing in the network when needed for veterans care and addresses clinical staffing shortages through graduate medical education and improving va hiring and retention of staff. I would just tell you that the caring for our veterans act checks every one of those boxes. And it checks every one of those boxes because when we drafted it, he we had those tenants in mind. I would really look forward to strong press release in support of this bill. Ill tell you why. Senator moran, chairman and myself and other members of this committee that youve been silent. So thank you. Section 211 of accountability over the past year thavengs to the good work of the chairman. When will we see this report . The report was due in december of 2017. So i apologize that it is not there. The staff has had extreme difficulty tracking what youve required in that report prior to the implementation of the accountability act. Ive instructed them to give whatever data they have to you and tell you what data they can collect. When can we expect it . Im going to say is it reasonable to ask for two weeks . Two weeks it is. Well hold you to it. Predecessors have testified that leadership includes working with underperforming employees to make them better at their jobs rather than just firing them. Is that your philosophy, too . Yes, it is, that every good manager works with their employees to make them better, to give them feedback. When an employee deviates from a professional, moral standard, sometimes you cant coach them, sometimes you have to help them find new work. You believe that your leadership is doing that within the va . I think we have room for improvement. When you look at our Employee Engagement skills theyre not improving the way that i believe that they should. Were relooking at our efforts to do that better. On the choice bill that was passed last august, Congress Expanded your direct hiring authority force positions for which there was a shortage of highly qualified candidates. Am i correct that they still do not use this authority to hire . Yeah. My understanding, senator, is that the direct Hire Authority was given to us for Medical Center directors and Network Directors and i think unintentionally it capped the salary were able to offer at a salary that is lower than what we currently offer. So weve not been able to utilize the direct Hire Authority in the way i believe was intended to be used. How can that be fixed . Very small, technical fibs. Youll have to do it legislatively. Its a very small technical change that weve given Technical Advice on. And it gives you authority on those positions but it also gave you authority for employees viewed as critical . Weve gone with 15 different critical occupations that they have agreed to move forward with us on direct Hire Authority that i believe we will start to implement in the next several weeks. Okay. So weve had the conversation before. I will tell you the first question that came up was workforce vacancies. This is just montana. Sorry about being self centered on this. Were in a crisis. We may in a crisis in other states. I dont know that but billings, supposed to have seven docs in that clinic. Weve got four and two of those are looking for another position. When you overwork employees, they tend to hit the road. Yep. My question is, whats the problem . Ive talked to you many times. I know youre committed to this. It seems like its getting worse. In fact, it doesnt seem like it. In my state, its getting worse. In montana, as you know, you have an 11. 2 turnover for employees. For physicians its 23 . Thats a problem. You have a 24 vacatincy rate. I got all that. What are we doing to fix it . What are you doing . First of all we have to hire more staff and make sure we keep them. We have announced for montana an increase of up to 120,000 for primary care physicians sbed kagsal Debt Reduction for nurses im sorry, for psychologists and nurse practitioners, a 10,000 hiring bonus and for social workers a 5,000 hiring bonus. Thats a beginning to start to address people, to look at the va as a place to come to work. Then we have to, as you said, if we cant fully staff, it puts more pressure on our current staff that are there and so its a vicious cycle. So we are working to recruit. Thank you for that. Time is of the essence. I dont speak for senator rounds. Hell speak for himself on this. As you well know, theres a house bill that was going to have they could shut down damn near every facility if they did a brac because we have no staffing. This is really, really, really important. It is. It is. Thank you. Absolutely. Ranking members cooperation throughout the process of working on Choice Legislation has been stupendous. Were going to get to support good legislation. Appreciate it very much. Mr. Boseman . Thank you. Thank you mr. Chairman and thank you, secretary, for being here. We do appreciate your hard work. I would like to talk to you for a second about a bill which we were able to be a vet tech act. Its a pilot. We dont have a deputy undersecretary for economic opportunity. Hes retired. Who is going to be responsible for implementing it and how were doing. Yeah. Talk a little bit more about yeah. Again you might also elaborate even more about how we can help you with these really key, you know, things that are deficient in the sense of not being properly staffed. I think it helped a great deal with the forever g. I. Bill. Its a Great Success story of what this community was able to do in 2017. As you know, of the gi bill, forever gi bill weve enacted already 13 of 34 of the provisions. But the one that youre talking about, the tech act, which is more the stem, scientific technical training, that is going to require thats one of the ones we havent yet implemented. Its going to require some i. T. Solutions. What were doing is we have an rfi out now to look to how we can get private industry, to help us implement that. Otherwise, were going to need to build that inhouse, which will be more expensive. So, we are looking for the best way to get that implemented and committed to getting it implemented. But on many of these of the 34, 22 of the provisions require i. T. Assistance. How will you determine the courses that are eligible, such as coding, things like that . Under the tech act. Yeah. Well, you asked who is responsible for it. Our act the undersecretary for benefits plrks tom murphy, has accountability under that area. Rob whorley, with us today, is the education director of educational benefits. According to the va oig patient account center, in 2015 the va billed thirdparty payers 7. 2 billion for medical treatment. I think we collected about 2. 5 billion. The department considers Third Party Collections as revenue. Budget projections. How does the va project its expected collections for each year and how does that match up with what were actually collecting . Yeah. We do give our projected collections as part of our budget request. Its an offset to essentially our whats given to us in our budget. Our finance team does the projections based upon actuals of last year and then sets the target for improvement. And this is something that we have targeted, improved collections. One of the provisions that i think is being considered under the current legislation is a requirement to disclose Third Party Insurance because thats part of the challenge that we have. If we dont know a veteran has other insurance, its very hard for us to go and collect it. So thats something that were working on. Right. I believe we have a Pilot Program going on in five areas . Yes. In relation to this. Do you have any on the Third Party Collection efforts. Exactly. Yeah. Thats not done. Do you have any preliminary things that you can talk to us about . I dont have an update. I dont know if anybody behind me has an update on that. I dont think theres an expert on that. I can get you that update. Thank you, mr. Chairman. Thank you, senator boseman. Let me take the liberty if i can of asking Gretchen Blum to stand up behind me. Gretchen has been with the committee since i came to the committee as chairman. She is going to Greener Pastures in oregon, a beautiful coastline. Lots of veterans and lots of people. Shes been a tremendous help to veterans and this committee. Thank you for your service. Thank you. Thank you, mr. Chairman. Appreciate it. Thank you for being here. I need to bring something of a local interest to your attention. High risk contacted my office after bypass surgery was canceled. Johnson clarksburg veteran, great hospital. The reason being that the spots were found on the tools processed. Let me tell you the time elapsed. Weve been told that theyve estimated its been ten weeks since a temporary just before a temporary sterilization unit will be operational. It will also take a whopping 16 to 18 months to replace the one thats deficient. Its been reported up to five level. Thats your region. I dont know if its ever gotten to you all. Theres got to be something, doctor, when something this egregious happens. We cant do anything about it. Were done. This is a big hospital. Of course. We need your help. Absolutely. Thank you. I need your help on that. Next of all, i sent a letter last week after the reading of the New York Times story, that the oregon va Medical Center has tried to improve the quality metrics. We start looking into this, how it affects us in our state. I found that the Emergency Department medium time for administering pain medication statistic on hospice Hospital Compare website is listed as nonavailable. And also noted that no cases met the criteria. It seems unacceptable to me for an Emergency Department. How are you equipping local emergency medical staff to track and record these type of data and who in West Virginia is responsible for collecting at a tima . We couldnt find out from my office. Yeah, yeah, yeah. On hospitalcompare. Gov out of the department of health and Human Services are you all working with va used to have all of its data up there. And then due to contract issues with the department of health and Human Services, not va, they lost the ability to take va data. They are now actively working to get it back up by the end of this year. They will have all that data back up. We still collect and produce all that data and publish it ourselves on access to care. Va. Gov. We do have that data and make our comparisons to local hospitals. We would be glad to share that with you. We wish it were up on the Hospital Compare site. We think its a great site. By the end of the year hhs will have that back up for us. You know about opiate addiction in i state and throughout the entire veterans community. Its something of great concern. The president basically declared a medical Public Health emergency. Ive been appreciative of that. Im appreciative of what were getting but we havent gotten anything yet. I dont know how its affecting you all with your fight on opioid addiction and how that will help you. Were asking this money to flow not based on population but based on need where the greatest occurrences are. Have you seen any changes there . Also you all need to be recognized in an affirmative way for basically not allowing your va patients to dictate dispensing as part of the overall care theyre getting and what quality of care which could penalize your hospitals. Ethink you all changed that and helped to move that all the way through the whole department of Human Services. Right. Well, first of all, i participated in the president s commission. I think its important we brought the members of the committee to the cleveland va that has a 3 prescribing rate, lowest in the country, to see the best practices. That did make it into the report. Last week we started to publish at va. Every Medical Center, no other hospital in the country does this. It is available now so everybody can see. On your website . Its on our website, and finally let me say weve made a 41 reduction since our efforts began in 2010 with the opioid crisis. The key is not simply withdrawing opioids. These are patients in pain. We recognize that. Before we start opioids, before you reach for it first, are there alternatives to help relieve pain and not put your patient at risk of addiction . Thats what were really focused on. A lot of veterans, we have targets to withdraw opioids. We do not. We want doctors to continue to eliminate pain but we want them to make smart choices. Were doing the same thing. We dont want any patient to think theyre being penalized whatsoever. There are other alternative methods. Alternative drugs being developed right now that arent addictive. Absolutely. That being said the one that haunt mees and bother mees more is the homelessness. Weve had an increase in homelessness from 2016 and 2017. Yes. I cant even fathom how any veterans should ever not have a roof over their head. Right. And place to sleep for what theyve done for us. Whats happening there . As you know, from 2010 until now, weve had a 46 reduction in Homeless Veterans. We still have 40,000 Homeless Veterans, way, way too many. Female veterans is up 7 homelessness. Their rate went up 2 , going in the wrong direction. Overall. Five major cities in the country. But los angeles and seattle are the two that went up the most. We need a reboot to our program. We need to do this better. Were going to target seattle and los angeles in particular but not give up on progress everywhere else. Were going to be coming out with a new, improved approach. It is going to be more resources. I just want to follow up real quick. For us to know how many Homeless Veterans we have, we have to have them in our records somewhere. Yes. There has to be contact. Right. With that were not just saying they dropped off the records. We actually now know by name who most of the Homeless Veterans are. We do once a year whats called a point case workers . Absolutely. We have case workers for our Homeless Veterans. We do whats called a point in time count. Were going to do it here in washington january 28th. Ill be out there at midnight with other people, making sure we accurately do that assessment. I did it in los angeles two years ago. Thank you. Thank you, senator manchin. Senator tillis . Thank you, mr. Chair. Thank you, secretary sulkin. One thing mentioned in your opening comments that i want to get more information on, i knew and was glad that the department is showing some latitude and providing services to veterans with other than Honorable Discharge. Can you tell me about the scope of that and maybe the numbers of people that have been served to this point . Yep. Yep. As you know, were trying to decrease veteran suicide, doing the right thing for our veterans. Take a look at where our highest risk veteran suicide is, its in several categories. Homelessness and Homeless Veterans that dont have access to care, clearly. Thats why were targeting an end to that. Other than Honorable Discharge veterans, very higher risk. What we provided them with is an emergency Mental Health that provides all they have to do is show up, well give them 90 days of emergency Mental Health care, stabilize a crisis and get them into longer term treatment if thats whats required. So far, weve treated and have come to us for help 3200 veterans with other than Honorable Discharge. We were actually hoping the numbers are higher. Offer what period of time. Since we started this. I think its one of the early things we did as sevenlth i would say ten months ago maybe. Were actually hoping the numbers would get higher. So, we continue to get that message out, that if youre a veteran with that type of other than Honorable Discharge and you need help, please come and were going to help you. Now, what happens if you get somebody to maybe a stable. Yep. And you improve their condition . This is emergency Mental Health benefit. What next . Lets say they get sick and it doesnt relate to the Mental Health illness . We have not extended a General Health benefit. That is something that we would be glad to work with, you or other members of congress on. That would be something that we would have to work on legislatively. I dont feel i have the authority. I didnt think you did. We had a hearing in the personnel subcommittee for Senate Armed Services and it was focused on concussion and more data were getting that at least could make you argue that perhaps discharges in some cases for bad behavior actually related to other circumstances. I think this is a good step. The first thing is to try to stem any real tide of suicides through the emergency Mental Health service. I think we need to talk more about how we would manage this and consider the full life cycle and what we talked about for the sort of job that a man or woman did in military were exposed to events that science suggests could have had an impact on their mental faculties or perhaps behaves that led to their discharge. Thats something i would like to talk to you more about. Maybe you could give me a quick update on i know the medical Health Record project is going to go through phases and take a while to get done. Looks like youre using a template similar to the dod and you have resources in there. So in that case, just tell me what we could do to help you. I think thats a very, very important project that we want to see to conclusion. You need to make sure that you tell us when you set a new priority that potentially taps your ability to deliver on some of the commitments youre making. What about other you mentioned in your opening comments about you still feel like youre making incremental, not breakthrough things. What are we likely to see to you to get from, some of the incremental that needs to be done. But what are the breakthrough things that you are look at that may require your help to get it moving . Well, i think what im doing is trying to put out there that we need those breakthrough ideas. And i want to see an opportunity to get those ideas from you as well as our veteran advocacy groups like veteran organizations and others who have those ideas. I think that could come in many different ways. They could come technologically, through Management Practices or policy and legislation. Weve seen some of them legislatively that i think that this committee has been in the lead in doing this past year, like appeals modernization thats going to make a difference. I think that and ive said this, that we need to reorganize the way we do business in va from having a large central bureaucracy to being able to give people in the field more authority and accountability that goes along that way. And we need to change some of our Management Practices that, frankly, have grown stale. Whats happening in the private sector on health care and technology is the type of transformation that i think needs to happen within government as well. And were going to need to do that collaboratively. Thank you. Thank you, mr. Chair. Thank you, mr. Chairman. Thank you, doctor shulkin. Thank you to the men and women of va for all their extraordinary, dedicated work. I am going to be sending you today a letter that cites the need for stronger protections for the post 9 11 veterans under the post 9 11 gi bill benefits. Ive raised this issue with you during confirmation hearings in january last year. It has been almost a year. In fact, on february 13th, it will be a year since your confirmation. And, quite honestly, i am deeply dissatisfied with the lack of action under existing authority, 38 United States code, section 36. 96 to crack down on the predatory practices of forprofit schools like corinthian and itt that have exploited our veterans. This letter sets forth in detail what those actions have been and why i think that the lack of action by the va has been troubling. And i know that you are sympathetic to this cause but i would like to see good words followed by action. And i will appreciate a response in my letter. I ask that it be made part of the record, mr. Chairman. Im asking that my letter to secretary shulkin of today be made part of the record. I want to focus right now on deeply troubling in fact, appalling incident in west haven. Im sure youre aware of it by now. The west haven va has been sued by a veteran who is alleging apparently a truly egregious act of malpractice. The veteran claims that a scalpel was left in his abdomen during a 2013 surgery and it was discovered only after years of pain and dizziness. It was removed in april of 2017 after an mri by the va. On june 6th, 2017, the veteran says that he initiated an administrative claim under the federal tort claims act regarding this case of medical negligence. Over six months later the va has still not responded, incredibly, to the claim beyond a simple acknowledgement of its receipt. And so the veteran has now filed suit in federal court. My first question to you is, is the Department Investigating these specific allegations . Yeah. Yea yeah. First of all, in this case, the way that you characterize it is accurate. Its an event that should never happen and i am deeply sorry that any veteran should have to undergo this. Of course this was inadvertent on the surgeons part. When the surgeon discovered this both he, extraordinarily well trained on the yale factory, practiced at the va but also at ya lechlt went with the chairman of surgery at the va and acknowledged their mistake and apologized and takes responsiblity for it. While this is an extremely rare event, happens in the country 1500 times a year. In the va it does happen. It happened 12 times in the va. Thats a rate in the va much less than what happens outside the va. Thats no excuse. This should never happen and were looking and root cause analysis has been done. Its been presented at the yale new haven mortality and morb idity conference so it could be examined by peers across the system. This veteran has suffered enough. Fortunately his first surgery which was done was a successful surgery, but he should not have to go through any more hassle in being acknowledged for what happened. And we will take responsibility for that. Part of taking responsibility is to acknowledge and act on his claim. Absolutely. And respond positively to the request that he made for relief under the federal tort claims act. I agree with that. It doesnt require any court proceeding. The va has an administrative and moral responsibility to respond and im disappointed it hasnt done so. Will you commit to doing so . Everything youre shaaying i share your sentiments and absolutely we will commit to that. I would also like a commitment because of your own background professionally as head of the university of pennsylvania medical system and other positions that youve held, you are very, very attentive to the standards of professional responsibility. I would also like a commitment that the va protocol and practices will be reviewed so that, in fact, this incident can be a teaching moment. You have that commitment. Patient safety is my passion. I personally spoke to the chairman of surgery at the west haven va. I know that she and this surgeon have taken this extremely seriously and are using this for the way that you and i both believe we should learn the va does have a practice across the va system for xrays to be done in some highrisk cases. Were reevaluating whether we should be doing more on top of that. Because these events should never happen. Were going to get committed to making it a safer environment. I appreciate your being so far coming. And im going to follow up and stay on it. Because i know youre committed to it. Ive seen the xray showing the scalpel. So have i. And, frankly, i was appalled. Sure. Surprised and grateful that this veteran is still alive. Yes. So thank you for your responses to my questions. Thank you, sir. Thank you, mr. Chairman. Senator hal hellburn . Thank you. Weve passed out ten pieces of legislation, so much have been mine and all of them have contained my priorities. I want to tell both of you i appreciate being part of this committee. For the leadership we have with this committee, past legislation, for example, g. I. Bill for life, access for stem but appeals process for faster disability claims efforts. Clearly the work is not over. This committee has probably already shared that with you a few times. Getting to your first year anniversary. I actually believe its february 14th. How do you like your job . I know youve been with the va a while but not in the capacity as secretary. How do you feel about the work thats progressing . Senator, first of all, its an honor and a privilege to be able to serve our veterans. Thats why im here. Im a tough grader on myself and my staff and we have a lot to do and were going to stick to it. A lot of credit goes to you and the house also, who is doing good work on their side to be able to make the progress that were making. I think we can all do better. I appreciate your visits to my state. The rural portions have expressed some concerns and probably the one that caught my attention the most and, frankly, for that matter my staff was the cancellation of the Community Care network. Yeah. For region four. Nevada, alaska, hawaii, california. We can go down the list. Its quite a region. Can you explain to me what the situation is and why my staff and congressional offices did not hear about this . We found out on friday. I dont know if it was out earlier than that we bu we found out on friday. I also found out last week, too. The federal contracting process is a complex process, one that is difficult, sometimes, to understand. It is designed to keep the people that run the business like myself out of negotiating these contracts. Thats why i found out the same week that you did. We divided the country up into four reasonablegions. Im disappointed we werent able to award it as well. The reason we were not able to award it is because our Contracting Officers did not believe that it was in trt of taxpayers to proceed with that contract. That means they did not believe that they should be paying the price that was being bid out there. They did not feel it was reasonable. This will be rebid and we hope and weve spoken to those that bid, they will rebid again because we believe that the quality of the contractors were there. It just wasnt we werent able to reach something that made sense for the taxpayers. Its my understanding that the competitive process has been closed down. Yes. What does it mean short term for someone who lives in eureka for these veterans that have is to travel long distances to get health care if theyre not proceeded in their communities . Right now were talking about your veterans are being served by a third partin administrator that runs many of the aspects of the Choice Program and that will continue. We think that that contractor right now is doing a good job improving its service to your veterans. Weve been in direct contact about issues and theyve been very responsive about fixing them. Business as usual, it will continue to be to serve the veterans. The contractor currently is committed to that. And we hope to have a xeef rebid process that will result in a good outcome for veterans, contractors but poerimportantly taxpayers sbl my time has run out. Thank you for coming to the state, spending time with the veterans, your accessibility. We look forward to working with you. Thank you very much. Thank you, mr. Chairman. The fact that the va has a large number of vacancies throughout the country not only in mountnt but also hawaii, and the va was given tools to make the hiring yet we seem to continuously be behind the eight ball. Have you put your finger on why it is that it is so hard . I realize there are lack of certain kinds of medical professionals, et cetera. If thats the overall problem, are there additional tools we can give the va to enable you to hire the necessary people . Well, yes. Yes, i do think that theres more we could do. Let me, senator, let me tell you, last year we actually made progress. We have a net increase of 8303 employees. We hired close to 40,000 but its a net increase of 8,303. But we know where we have critical vacancies. Thats where we want to move towards a direct Hire Authority that senator tester talked about. Opm has been very helpful to us and indicated their support in doing that. There is this technical fix we talked about that will help us implement your intent last year when you gave us direct Hire Authority. Do you need additional tools . We do. We do. What are they . We want to continue to right now we have three hiring authorities that we have to hire employees under. Its complicated. Title v, title 38. The more we can move toward title 38 it makes the process fast and more competitive with the private sector. Will that take legislation . Its something that i think we have the authority to do ourselves and thats what were moving towards. Weve come to you in the past and will if we need it. Please do because i know in hawaii there are vacancies that need to be addressed. Last week, an executive order supporting our veterans to civilian life and ensurie ining access to Mental Health care and saw side prevention, which you talked about, as a priority. One of the provisions calls for access for veterans to receive Mental Health care. I want to know whether you have enough Mental Health care professionals and what do you plan to do for Additional Resources to recruit and maintain Mental Health professionals . I assume thats one of your shortages. Yes. Thank you for acknowledging the executive order. If you look at any group thats at the high risk for suicide, it is that 12month period from transition. So this is targeted to providing every single transitioning Service Member with a Mental Health benefit. I think thats critically important. In order to do that, va does need more Mental Health professionals. We have identified the need for 1,000 Mental Health professionals. Unfortunately the country at large has a shortage of Mental Health professionals. This is going to be difficult. We work hard with psychologists and psychiatrists to train as many as we can. We want to do more. We will continue to use efforts like our recruitment bonuses and to acknowledge that va is actually a terrific place to work if youre a Mental Health professional. Hawaii will be a great place to be. Yes. So were going to do whatever we can. Thank you. I want to get to the ig report that showed overpayments and payment errors in the Choice Program. Since im running out of time, clearly what we need to be assured that you are taking the appropriate steps to make sure that you have processes in place. That these overpayments are not occurring. Yes. Veteran homelessness, your predecessor made a commitment that he would eliminate homelessness. We seem to be going in the wrong direction here in particular with women veterans. What are you doing about it . By the way, where is any homelessness in your order of priorities for the va . The commitment to ending veteran homelessness, i think you correctly said, was made in 2010. We will not back down from that goal. And we will continue to drive to do everything we can to end veterans homelessness so that there is no there is the same firm commitment. What ive said is because of this last year, where we actually went up 2 , we have to rethink our effort. Any Good Business looks at what theyre doing and says if theres a better way to do it, we should. So were going to come out with a new approach that doubles down on the things that are working and maybe uses resources from things that arent working as well. So here is what we know is working and ill tell you whats not working. Veterans get jobs, it keeps them in sustainable housing. It helps in so many ways. Were going to redouble down on working with employers around the country to find our Homeless Veterans and train them and get them jobs. Number two, the hud Voucher Program works really well. We want to continue that partnership with hud. We look toward areas, hawaii is one, but los angeles and seattle, too, where the what the value of your voucher, you cant find people who want to rent you apartments. So we have to continue to increase the value of that. So were working on that. We have a shortage of Affordable Housing units. We need to partner with construction people and landlords and actually create more inventory of low inventory housing. Thats going to work. We need more Community Partnerships. We just because va cant do this alone. Hud cant do this alone. Its a countrywide commitment. Were going to double down on the things that work and come out with a fresh new approach here. We would like to work with you on this because im not satisfied with the progress were making. Let us know how thats going. Especially hawaii has per capita the highest number of homelessness in the entire country. The Housing Market is so expensive. Thank you. Senator cassidy . Secretary shulkin, how are you . A lot of what im going to be asking you today references an article written in october of last year. Mr. Levine, im sure youre familiar with it in newsweek about how the va fueled the National Opioid crisis and is killing thousands of veterans. As you might guess from the title its critical. Yes. Ive heard or read that youve now published facility specific statistics as regarding the prescriptions. Ive been interested in big data in terms of applying to the va, knowing facility specific. For whatever reason weve not quite got there yet. The article speaks of in huntington, West Virginia, the local va prescribes takehome opiates to roughly 18 of its patients, 230 rate higher than the National Average for all adult male patients. I have not looked at these statistics you released. Does this va still prescribe as an outliar such as that . What we pressure now and senator cassidy, i hope youll appreciate this. No other system has ever published this data. Were hope they go will join us. Youll see what our rate is now, what it was in 2012 and whether theyve made improvements. Every single site except for one has made improvements in their prescribing rates in opioids. The one who didnt may be somewhat unique. Its in the philippines. Its manila. Every domestic site in the va has made improvements. Lot more than others and thats where we hope theyll learn from each other. So i dont recall huntington, West Virginias improvement rate but know its improved. Sharing data with pdmps, state physician. Yeah. By the end of last year, which would have been 2016, 18 state programs 18 state va programs still werent reporting. Is that still the case . Now a year out from this . I do not believe thats the case anymore. Im going to want to confirm with you that were in 100 compliance but that is our commitment. And if were not in 100 compliance, im going to want to know about that because weve committed to that. And we should be. It also suggests that your vista Electronic Medical program is incapable of flagging drug interactions between valiums and opioids and riddlin and everything in every class as well as one patient who got 130, i think i recall this, 130 morphine tabs. Thats kind of eye popping. Why would you get so much . Is vista capable of flagging this . Are the pharmacy programs incapable of seeing these drug interactions and flagging them . We do measure and follow the statistics on patients who are on both, benzodiazapimes and opioids because of the danger. We have drug interactions that come up on vista. I see them when i use vista. Im not able to tell you why we wouldnt be able to do that. The pharmacist quoted says it does not flag it. Apparently he testified that under oath. Yeah. Yeah. And, again, i just dont know the answer to that. I would like to i would be glad to confirm with you very shortly whether that is the case or not, or whether thats been fixed. I dont know what technological reason we wouldnt be able to do it but i understand that. Let me ask you mentioned how many fewer patients are now opioid dose something going down. Does the va have any spot checks as to how many veterans have gone from receiving prescription opioids to perhaps seeking out illicit opioids . Is it an apparent victory or perceived victory . I dont know what theyre doing illegally. Do we have drug screens that might show theyre still taking them . Those that return and have been started on opioids sign a patient informed consent that says that we will do the urine screening and we do the urine screenings and we report on that in terms of general statistics. But if a veteran doesnt return to us, we dont have any way of tracking them. Any sense of the number or percent of opioid overdoses in people who theoretically are no longer taking opioids . We do track narcan use, distribute a lot of narcan that hopefully would be a measure of people who have overdosed and weve been able to resuscitate. Ive never seen the data broken down. I think that would be helpful to the committee because that would let us know whether or not were making progress on whether its more apparent than real. Is it the va using medicationassisted therapy for those who are addicted . Yes. Suboxone and other assisted treatments. Were seeing a rise in that and certainly we are keeping up with a contrary littemporary literat that. A rise could be from a small baseline and still be very small. Could you submit for the record the percent of patients you think have opioid use issues . I would be glad to get you those statistics. My impression is i havent looked at this in detail in the recent, is that your representation is probably correct, starting from a small baseline, beginning to use it more. Still probably underutilized. And an opportunity for us to do better. I yield back and apologize for going over. Senator murray . Thank you very much, mr. Chairman. Secretary, thank you for being here today. Last year, the government tried to take money away from important issues and try to spend it on literally anything. Youve come to us repeatedly, sometimes days or weeks left, saying va will run out of funding for the Choice Program earlier than expected. The department has to start being transparent with congress about its budget needs and not writing critical programs to cover these shortfalls and give us, finally, a realistic picture of Community Care spending. Those are really basic expectations. How much youre spending and ask for what you really need. So i wanted to ask you today, will there be any changes in how va manages its Business Operations or is it time to consider a new approach to these functions . Yeah. Yeah. Well, first of all, i think those are fair criticisms. And i have to take responsibility. This is a system were trying to do so much and so fast were obviously making some mistakes and have to do better at that. The projections on the Choice Program, financial projections are very, very complex to do. Largely because not only but largely because of this issue we hope to get fixed with your committees bill that we have to committee the money at the time of we have to obligate the money at the time we order the service, not when it was rendered. Its a little bit of a guessing game that makes financial projections hard. But were doing better. We projected that the money would run out first or second week in january and it did. You gave us 2. 1 billion. Today we have 2 billion left. Which means we spent 100 million already of what you spent us. Were Getting Better. We have a brand new cfo just confirmed, thanks to you, in the last two weeks. Its a hard job to do and well never get totally accurate unless we get these rules changed. Taking money away from hud voucherors Womens Services, absolutely never, never our intent to spend less money for Womens Services or hud or Mental Health or anything else. Here was our intent. I stopped it because of the reason that you said. It was not accurately being rolled out or communicated. So its not happening now. Let me tell you what my intent was. If you disagree with it, i would like to talk with you. Right now everything is controlled in washington out of a central office. We tell people this is how much you get and this is where you need to spend it. My idea of management is you let the people closer to where youre serving the veteran be more involved in how they spend their money and they have to be accountable for results. Treating more women veterans, getting more Homeless Veterans off the street but allow them to understand whats better in seattle than whats better in honolulu. I was trying to advocate a management philosophy that has worked for me that i believe in. It was not rolled out well. So i stopped it. But were going to think about how to make the system work better. What we need to do better and im going to continue to try to do it. But i am going to commit, were going to do a better job at being transparent and collaborative with you. Thats what we will be watching for. Got it. Thats fair. We had a rough year but thats what well be watching for. Thats fair. Let me move to another topic. Inspector general report from december found in six of seven Medical Centers it re reviewed primary care provider panels were significantly below required levels. And that vha did not provide oversight of that requirement. That resulted in decreased access for our veterans and hundreds of thousands of dollars in waste that were not filled. Reported wait times are misleading. In this case, by the igs calculation, more than half of the newly enrolling veterans waited longer than 30 days for their first appointment. Another ig report found that Eastern Colorado Health Care System is still keeping secret waiting lists for group Mental Health care therapy and finally, according to va data from november, 45,000 vacancies, seniorlevel shortcomings across the system that end up with reducing access to our veterans for care and wasting taxpayer dollars. Who is accountable here . Im accountable. But and theres no but about the accountability. The statistics that youre reporting this is not being defensive. I want you to understand what they are. 35,000 vacancies. We have 370,000 employees, a 9 vacancy rate, which is not overly high. So youre always going to have 40,000 vacancies during the course of the year. The 35,000 are part of that turnover rate. And as i mentioned we had 8,303 employees last year. That waiting list for group Mental Health care, wait times. This is all from the ig. Im not making this up. No. I got it. We have a big system. Secret wait times, we have clearly said to all of our leadership not to occur, not acceptable. If we find them, there are disciplinary actions n colorado, i think that this was one cli c clinic, and i may stand corrected. I believe that the facility actually identified that, dealt with that issue. This is not representative of whats happening across the country. Wait times, we continue to struggle with. Weve made progress. Theres no doubt that the data says we made progress. Were not anywhere near where we need to be. No, were not. And were working on it and making progress every day. What weve indicated are progress is in matching clinical urgency and need to access. This goes back to my original question. We need you to tell us how much youre spending and what you are asking for these veterans. We need to know that. Yep. Okay. Thank you. Sullivan is recognized for the patience of jobe award. Thank you, mr. Chairman. Mr. Secretary, good to see you. Ill going to start with some thanks and kudos to you and your team. We finally passed out of the committee here the serving our rural veterans act, which was senator tester and is bill. You were kind of the brainstorm that have when you and i were alaska. So, your team and i, we all worked together and got that across the senate floor. I want to thank you for helping inspire the idea and having the team and i want to thank you, dr. Ballasm rd in alaska is doing a great job. Good. Weve added over 100 employees, including two docs which we havent had a doctor there in, i think, five years. Kind of a crisis situation that senator tester is talking about. We filled it. And i know you had a focus on that. I was in the peninsula with some constituents having coffee. One of them asked me, hey, what are we doing, senator, on suicide. You know, older gentleman really concerned. Talked about the clay hunt Suicide Prevention act and some of the other issues